Provider Demographics
NPI:1508005562
Name:FRIEND, KATHREEN KELLI (PEDIATRIC NURSE PRAC)
Entity Type:Individual
Prefix:MS
First Name:KATHREEN
Middle Name:KELLI
Last Name:FRIEND
Suffix:
Gender:F
Credentials:PEDIATRIC NURSE PRAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 SUNNY ACRES DR
Mailing Address - Street 2:
Mailing Address - City:DONIPHAN
Mailing Address - State:MO
Mailing Address - Zip Code:63935-1546
Mailing Address - Country:US
Mailing Address - Phone:573-996-5292
Mailing Address - Fax:
Practice Address - Street 1:109 LEROUX ST
Practice Address - Street 2:
Practice Address - City:DONIPHAN
Practice Address - State:MO
Practice Address - Zip Code:63935-1038
Practice Address - Country:US
Practice Address - Phone:573-336-2136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-16
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002019510363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics